本文選題：大病　切入點(diǎn)：疾病經(jīng)濟(jì)風(fēng)險(xiǎn)　出處：《華中科技大學(xué)》2016年碩士論文

【摘要】：[目的]本研究著眼于我國(guó)農(nóng)村大病患者,基于UHC視角,對(duì)其面臨的疾病經(jīng)濟(jì)風(fēng)險(xiǎn)和影響因素以及新農(nóng)合和大病保險(xiǎn)抵御疾病經(jīng)濟(jì)風(fēng)險(xiǎn)的效果進(jìn)行系統(tǒng)評(píng)價(jià),對(duì)新農(nóng)合大病保險(xiǎn)制度提出完善建議,以提高其疾病經(jīng)濟(jì)風(fēng)險(xiǎn)抵御能力及公平性。[方法]本研究基于UHC視角,運(yùn)用“結(jié)構(gòu)—過(guò)程—結(jié)果”公共政策分析過(guò)程,構(gòu)建大病保險(xiǎn)評(píng)價(jià)指標(biāo)體系,對(duì)政策及補(bǔ)償效果進(jìn)行評(píng)述,并評(píng)價(jià)補(bǔ)償?shù)墓叫�。通過(guò)文獻(xiàn)查閱了解國(guó)內(nèi)外大病醫(yī)療保障的相關(guān)制度體系與疾病經(jīng)濟(jì)風(fēng)險(xiǎn)評(píng)價(jià)等,運(yùn)用文獻(xiàn)研究法研究與整理。通過(guò)機(jī)構(gòu)調(diào)查搜集樣本地區(qū)2010-2014年新農(nóng)合住院補(bǔ)償數(shù)據(jù)庫(kù),通過(guò)入戶問(wèn)卷調(diào)查獲取了472例大病患者就醫(yī)行為及費(fèi)用支出等情況,運(yùn)用描述性統(tǒng)計(jì)、Logistic回歸以及廣義線性模型對(duì)大病患者保障水平現(xiàn)狀及相關(guān)影響因素進(jìn)行分析,運(yùn)用災(zāi)難性衛(wèi)生支出發(fā)生率、災(zāi)難性衛(wèi)生支出相對(duì)差距等相關(guān)指標(biāo)與反事實(shí)分析法測(cè)量新農(nóng)合、大病保險(xiǎn)制度的抗疾病經(jīng)濟(jì)風(fēng)險(xiǎn)作用。同時(shí),通過(guò)災(zāi)難性衛(wèi)生支出集中指數(shù)評(píng)價(jià)新農(nóng)合以及大病保險(xiǎn)制度補(bǔ)償效果的公平性。通過(guò)關(guān)鍵人物訪談(新農(nóng)合管理部門、民政部門、衛(wèi)生行政部門領(lǐng)導(dǎo)和大病患者)了解農(nóng)村大病醫(yī)療保障存在的問(wèn)題與完善建議,運(yùn)用框架分析方法對(duì)其進(jìn)行結(jié)構(gòu)分析。[結(jié)果](1)通過(guò)全國(guó)各省市大病保險(xiǎn)政策梳理可知,各地區(qū)在制定大病保險(xiǎn)政策的時(shí)候,都基于本地實(shí)際情況同時(shí)權(quán)衡基金承受能力,盡可能拓展大病保險(xiǎn)覆蓋范圍和保障水平。在我國(guó)大病醫(yī)保的實(shí)施過(guò)程中,既存在三種基本醫(yī)療保險(xiǎn)之間的根本制度性差異,同時(shí)城鄉(xiāng)居民大病醫(yī)保制度在籌資標(biāo)準(zhǔn)、補(bǔ)償參數(shù)設(shè)置以及經(jīng)辦方式等方面也不盡相同。(2)通過(guò)對(duì)新農(nóng)合信息系統(tǒng)數(shù)據(jù)分析發(fā)現(xiàn),大病患者住院天數(shù)長(zhǎng),2013-2014年平均住院天數(shù)為37天。大部分大病患者(90.0%)都前往三級(jí)醫(yī)療機(jī)構(gòu)就診。相對(duì)新農(nóng)合住院患者,大病患者自付費(fèi)用較高,經(jīng)過(guò)新農(nóng)合以及大病保險(xiǎn)報(bào)銷后,自付費(fèi)用仍然高達(dá)24000元,且實(shí)際補(bǔ)償比較低(約為50%),不可報(bào)銷費(fèi)用所占比例高(約為27%)。由患者入戶調(diào)查數(shù)據(jù)庫(kù)可知,大病患者兩周就診率為25.2%,其中44.4%的大病患者前往地市級(jí)及以上醫(yī)療機(jī)構(gòu)就診,門診補(bǔ)償較少,僅為20.6%。此外,大病患者直接非醫(yī)療費(fèi)用與誤工損失均較高(人均直接非醫(yī)療費(fèi)用平均為3822元,人均誤工損失為7279元)。有11.4%的大病患者有應(yīng)就診而未就診的行為,有10.5%大病患者有應(yīng)住院而未住院情況,有21%的大病患者有放棄治療行為。大病患者總疾病經(jīng)濟(jì)負(fù)擔(dān)沉重,經(jīng)新農(nóng)合和大病保險(xiǎn)報(bào)銷后仍有31.3%的大病患者家庭發(fā)生災(zāi)難性衛(wèi)生支出。有72%大病的患者因病借債,人均借款金額高達(dá)46339元,52.5%的大病患者認(rèn)為疾病經(jīng)濟(jì)負(fù)擔(dān)很重。(3)教育水平、是否有醫(yī)療救助、基本醫(yī)療保險(xiǎn)報(bào)銷額度和大病保險(xiǎn)報(bào)銷額度是影響自付費(fèi)用的主要因素。教育水平高,自付費(fèi)用較低,沒(méi)有醫(yī)療救助的患者自付費(fèi)用是有醫(yī)療救助患者的1.02倍,基本醫(yī)療保險(xiǎn)/大病醫(yī)療保險(xiǎn)報(bào)銷額度每上升1個(gè)單位,大病患者自付費(fèi)用下降1個(gè)單位。(4)家庭收入、醫(yī)療費(fèi)用、基本醫(yī)保報(bào)銷額度和大病保險(xiǎn)報(bào)銷額度是影響災(zāi)難性衛(wèi)生支出的顯著性因素。低中收入家庭比高收入家庭更容易發(fā)生災(zāi)難性衛(wèi)生支出,其中,低收入家庭發(fā)生災(zāi)難性衛(wèi)生支出的概率是高收入家庭的2.747倍,中收入家庭發(fā)生災(zāi)難性衛(wèi)生支出的概率是高收入家庭的3.235倍。(5)經(jīng)新農(nóng)合補(bǔ)償后,災(zāi)難性衛(wèi)生支出發(fā)生率在原有基礎(chǔ)上降低了41.3%,經(jīng)大病保險(xiǎn)補(bǔ)償后,大病患者新農(nóng)合補(bǔ)償后大病保險(xiǎn)補(bǔ)償前降低12.2%,但是經(jīng)過(guò)新農(nóng)合和大病保險(xiǎn)報(bào)銷后災(zāi)難性衛(wèi)生支出發(fā)生率仍高達(dá)31.3%;新農(nóng)合和大病保險(xiǎn)的補(bǔ)償使災(zāi)難性衛(wèi)生支出相對(duì)差距在原有基礎(chǔ)上降低了38%和13%,但是補(bǔ)償后大病患者災(zāi)難性衛(wèi)生支出相對(duì)差距仍高達(dá)25%。(6)新農(nóng)合補(bǔ)償前災(zāi)難性衛(wèi)生支出的集中指數(shù)-0.714;新農(nóng)合補(bǔ)償后大病保險(xiǎn)補(bǔ)償前災(zāi)難性衛(wèi)生支出的集中指數(shù)-0.019;大病保險(xiǎn)補(bǔ)償后災(zāi)難性衛(wèi)生支出的集中指數(shù)-0.286。集中指數(shù)均為負(fù)值,這表明災(zāi)難性衛(wèi)生支出好發(fā)于貧困家庭,新農(nóng)合補(bǔ)償后,公平性顯著改善,但是大病保險(xiǎn)補(bǔ)償后,災(zāi)難性衛(wèi)生支出出現(xiàn)向貧困家庭轉(zhuǎn)移的趨勢(shì)。[結(jié)論](1)大病保險(xiǎn)制度體系已經(jīng)較為完備,但仍有完善空間。(2)大病保險(xiǎn)籌資渠道較為單一,需要拓寬籌資渠道,建立穩(wěn)定的籌資機(jī)制。為最大程度實(shí)現(xiàn)UHC,緩解大病患者疾病經(jīng)濟(jì)風(fēng)險(xiǎn),需要?jiǎng)討B(tài)調(diào)整優(yōu)化大病醫(yī)保補(bǔ)償模式,科學(xué)確定起付線,確定合理補(bǔ)償范圍和補(bǔ)償比例,保留或取消封頂線,與基本醫(yī)保在補(bǔ)償模式上有效契合,并精細(xì)測(cè)算,科學(xué)地確定大病醫(yī)保的基金支出規(guī)模,為確定適宜的籌資標(biāo)準(zhǔn)提供參考依據(jù)。(3)大病保險(xiǎn)實(shí)施刺激醫(yī)療衛(wèi)生服務(wù)需求釋放。大病保險(xiǎn)實(shí)施改善大病患者經(jīng)濟(jì)可及性,刺激需求釋放,有效促進(jìn)UHC。同時(shí),也應(yīng)注意道德風(fēng)險(xiǎn)防范,管控不合理需求釋放,科學(xué)控制醫(yī)療費(fèi)用不合理增長(zhǎng)。(4)大病保險(xiǎn)緩解了疾病經(jīng)濟(jì)風(fēng)險(xiǎn),但效果有限,且加劇了不公平。后期應(yīng)該從人口、服務(wù)、直接費(fèi)用三個(gè)維度完善大病保險(xiǎn)補(bǔ)償方案。擴(kuò)大大病保險(xiǎn)制度的覆蓋面,調(diào)節(jié)政策公平性,合理界定合規(guī)費(fèi)用,降低不可報(bào)銷比,在提高大病患者住院水平的同時(shí)夯實(shí)門診補(bǔ)償水平。(5)促進(jìn)基本醫(yī)療保險(xiǎn)、大病保險(xiǎn)和大病醫(yī)療救助有效銜接。大病保險(xiǎn)應(yīng)根據(jù)基本醫(yī)療保險(xiǎn)保障水平科學(xué)制定保障參數(shù),并動(dòng)態(tài)調(diào)整。有效彌補(bǔ)基本醫(yī)療保險(xiǎn)市外就診報(bào)銷比例偏低、報(bào)銷目錄窄、門診保障水平低的問(wèn)題。擴(kuò)大對(duì)中低收入人群的保障,提高公平性。同時(shí)實(shí)行大病醫(yī)療救助對(duì)高自付費(fèi)用患者和貧困人群進(jìn)行“兜底”,從大病概念、保障對(duì)象、保障水平、結(jié)算時(shí)限等多方面與大病保險(xiǎn)有效銜接。
[Abstract]:[Objective] this study focuses on the rural patients with serious illness in China, based on the perspective of UHC, to evaluate the effect of the disease economic risk and the influential factors of new rural cooperative medical insurance against disease economic risk, puts forward some suggestions on the new rural cooperative medical insurance system, to improve its ability to resist the disease economic risk and the fairness of the method. This study based on the perspective of UHC, using the "structure process outcome" of public policy analysis, construct the evaluation index system of serious illness insurance, review the policy and compensation effect, and to evaluate the fairness of compensation. Through literature review to understand the disease economic risk evaluation system and related system of domestic and foreign medical security, application research with the literature research method. Through the survey to collect 2010-2014 samples in hospital NCMS compensation database, through the questionnaire survey obtained 472 cases of patients with serious illness medical behavior and expense etc., by using descriptive statistics, Logistic regression and generalized linear model of factors present situation and related security level in patients with serious illness were analyzed, using the incidence of catastrophic health expenditure and related indicators of catastrophic health expenditure relative gap and counterfactual analysis method to measure the NCMS, the effect of anti economic risk the disease illness insurance system. At the same time, the fairness of the catastrophic health expenditure concentrated compensation effect evaluation index and NCMS illness insurance system. Through key informant interviews (new agricultural management department, civil affairs department, the administrative department of health and illness leading patients) understanding of rural catastrophic medical security problems and suggestions, use the framework of analysis the method is analyzed. The structure of the] (1) by various provinces and cities nationwide illness insurance policy combing the area of the When making a serious illness insurance policy, are based on the actual situation of the local fund balance and affordability, as far as possible to expand the coverage and security level of serious illness insurance. In the implementation process of China's serious illness insurance, the existing basic system between the three kinds of basic medical insurance and the difference between urban and rural residents illness insurance system in financing standard, the compensation parameter setting and handling methods are not the same. (2) based on the data of the new rural cooperative medical information system analysis found that patients with serious illness, hospitalization days long 2013-2014 years, the average hospital stay was 37 days. Most of the patients (90%) at the three level medical institutions. The relative hospital patients, patients with serious illness since pay higher fees, and after NCMS illness insurance reimbursement, payment is still as high as 24000 yuan, and the actual compensation is relatively low (about 50%), do not report the proportion of the cost of high pin (about 27%). The patients with household survey data show that patients with serious illness two week visiting rate was 25.2%, of which 44.4% of the patients with serious illness to the municipal level and above medical institutions, outpatient compensation is less, only 20.6%. in patients with serious illness, non medical costs and lost income losses were higher (per capita non medical costs an average of 3822 yuan, loss of 7279 yuan per capita). 11.4% of the patients with serious illness should be treatment without treatment of 10.5% patients with serious illness, hospitalization, 21% patients with serious illness to give up treatment in patients with serious illness behavior. The total economic burden of disease is heavy, and the NCMS illness insurance reimbursement is still 31.3% of the patients with serious illness, family catastrophic health expenditure. There are 72% serious illness patients due to debt per capita loan amount up to 46339 yuan, 52.5% of the patients with serious illness that disease economic burden is very heavy. (3) the level of education is. Any medical assistance, the basic medical insurance reimbursement and illness insurance reimbursement amount is the main factors influence expense. High levels of education, cost is low, no Medicaid patients cost is 1.02 times with medical assistance, the basic medical insurance / medical insurance reimbursement amount for every increase of 1 unit, ill patients cost decreased 1 units. (4) the family income, medical expenses, basic medical insurance reimbursement and illness insurance reimbursement amount is significant influencing factors of catastrophic health expenditure. Low income families in high-income families are more prone to catastrophic health expenditure, the probability of low income family disaster the health expenditure is 2.747 times as high income families, low-income families in the probability of catastrophic health expenditure is 3.235 times as high income families. (5) the compensation after the catastrophic health expenditure On the basis of the original incidence rate decreased by 41.3%, after a serious illness insurance compensation, patients with serious illness, serious illness insurance compensation compensation after a 12.2% reduction, but after the new rural cooperative medical insurance reimbursement after the occurrence of catastrophic health expenditure rate is still as high as 31.3%; new rural cooperative medical insurance compensation to catastrophic health expenditure relative gap on the basis of the original decreased by 38% and 13%, but the relative gap compensation after illness patients with catastrophic health expenditure is still as high as 25%. (6) compensation before the concentration index of catastrophic health expenditure -0.714 concentration index; serious illness insurance compensation compensation after the catastrophic health expenditure index -0.019; serious illness insurance compensation after the concentration index of catastrophic health expenditure -0.286. concentration was negative, suggesting that catastrophic health expenditure occurs in poor families, compensation, fairness significantly improved, but the serious illness insurance compensation After compensation, catastrophic health expenditure transfer to poor families. The trend of conclusion] (1) system of illness insurance system has been relatively complete, but there is still a perfect space. (2) a serious illness insurance financing channel is relatively single, to broaden the financing channels, establishing a stable financing mechanism. In order to achieve the greatest degree of UHC, alleviate the patients with serious illness the disease economic risk, dynamic adjustment and optimization of illness insurance compensation mode, scientifically determine the pay line, determine the reasonable scope of compensation and compensation ratio, retention or cancel the top line, basic medical insurance and effectively fit in the compensation mode, and fine calculation, scientifically determine the illness insurance fund expenditure scale, and provide the reference for the determination of appropriate financing standard. (3) a serious illness insurance stimulus medical service demand release. Patients with serious illness, serious illness insurance implementation to improve the economy and stimulate demand, effectively promote the release of UHC. at the same time, also Should pay attention to moral risk prevention, control unreasonable demand release, scientific control of medical expenses. (4) a serious illness insurance to ease the disease economic risk, but the effect is limited, and aggravate the unfair. The latter should from the population, the direct costs of the three dimensions of service, improve the serious illness insurance compensation. Expand insurance system the coverage of adjusting the policy of fairness, reasonable definition of compliance costs, reducing reimbursement ratio, increase in serious illness in hospitalized patients at the same level to reinforce the outpatient compensation level. (5) to promote the basic medical insurance, serious illness insurance and medical assistance effectively. Disease serious illness insurance should be formulated according to the basic medical insurance level science and security parameters, and dynamic adjustment. Effectively make up for the basic medical insurance of foreign medical reimbursement reimbursement list is low, narrow, low level of outpatient insurance problems. The expansion of low income guarantee, provided High fairness. At the same time the implementation of medical assistance to the high cost and poor people of patients reveal, from illness concept, security objects, security level, settlement time and other aspects and serious illness insurance effectively.

【學(xué)位授予單位】：華中科技大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R197.1;F842.684

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3 記者 王紫;我省個(gè)人衛(wèi)生支出低于全國(guó)水平[N];西寧晚報(bào);2013年

4 記者 王新紅;2015年起個(gè)人衛(wèi)生支出占比低于25%[N];阿克蘇日?qǐng)?bào)(漢);2013年

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7 本報(bào)記者 王世玲;衛(wèi)生部專家應(yīng)亞珍：居民個(gè)人現(xiàn)金衛(wèi)生支出比重將繼續(xù)下降[N];21世紀(jì)經(jīng)濟(jì)報(bào)道;2009年

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10 余峰 山西財(cái)經(jīng)大學(xué)華商學(xué)院;政府衛(wèi)生支出對(duì)我國(guó)居民醫(yī)療費(fèi)用的影響[N];山西經(jīng)濟(jì)日?qǐng)?bào);2010年

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2 楊亮;中國(guó)政府衛(wèi)生支出的問(wèn)題與對(duì)策[D];武漢大學(xué);2012年

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4 肖海翔;政府衛(wèi)生支出效率及其改進(jìn)研究[D];湖南大學(xué);2012年

5 王曉潔;中國(guó)公共衛(wèi)生支出理論與實(shí)證分析[D];中國(guó)人民大學(xué);2006年

6 楊學(xué)來(lái);基于籌資系統(tǒng)功能的衛(wèi)生籌資公平性研究[D];山東大學(xué);2013年

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6 李西同;重慶市住院患者家庭災(zāi)難性衛(wèi)生支出及其影響因素研究[D];重慶醫(yī)科大學(xué);2016年

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